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Amanda E. Brunton, MS, MPH1 Radmila Choate, PhD, MPH2 Christopher J. Richards, MD3 George M. Solomon, MD4
Author Affiliations
- Bronchiectasis and NTM Association, Miami, Florida, United States
- Department of Epidemiology and Environmental Health, College of Public Health, University of Kentucky, Lexington, Kentucky, United States
- Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
Address correspondence to:
George M. Solomon, MD
1900 University Blvd - THT 422
Birmingham, AL 35294
Phone: (205) 996-4975
Email: gsolomon@uabmc.edu
Abstract
Background: Airway clearance techniques (ACTs) are required in international bronchiectasis (BE) management guidelines, and high-frequency chest wall oscillation (HFCWO) is the only ACT with a Centers for Medicare and Medicaid Services (CMS) reimbursement guideline.
Objective: We aimed to compare patient demographics and clinical characteristics between BE patients using HFCWO to BE patients not using HFCWO.
Methods: Bronchiectasis and Nontuberculous Mycobacteria Research Registry (2008–2025) data were retrospectively analyzed. Patients were grouped by baseline HFCWO use and nonusers were further stratified by selected CMS eligibility criteria (productive cough or more than 2 exacerbations per year) and subsequent HFCWO utilization.
Results: Of 5673 patients (median age 69 years), 518 used HFCWO and 5155 did not. HFCWO users had higher rates of asthma (31.7% versus 25.3%, P=0.002), gastroesophageal reflux disease (48.5% versus 41.9%, P=0.004), primary ciliary dyskinesia (5.8% versus 2.1%, P<0.001), allergic bronchopulmonary aspergillosis (3.3% versus 1.7%, P=0.013), and nontuberculous mycobacteria (20.1% versus 15.7%, P=0.011). Symptoms more common in HFCWO users included dyspnea (72.1% versus 38.5%), fatigue (61.5% versus 46.8%), cough (90.9% versus 76.6%,), and hemoptysis (27.1% versus 19.8%) (all P<0.001). The median modified Bronchiectasis Severity Index score was higher in HFCWO users (8 versus 7, P<0.001), and HFCWO users more frequently received antibiotics, bronchodilators, hypertonic saline, and inhaled and oral corticosteroids, indicating greater disease burden. Notably, 58% (2703/4679) of non-HFCWO users appeared to meet selected CMS symptom/exacerbation criteria and their characteristics resembled HFCWO users.
Conclusion: These findings suggest areas to explore to standardize BE management and motivate clearer treatment guidelines to optimize patient health outcomes.
Citation
Citation: Brunton AE, Choate R, Richards CJ, Solomon GM. Low incidence of high-frequency chest wall oscillation in bronchiectasis registry data despite indications and reimbursement. Chronic Obstr Pulm Dis. 2026; 13(5): 343-351. doi: http://dx.doi.org/10.15326/jcopdf.2026.0806
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Mariah K. Jackson, PhD, RDN1 Han Woo, PhD2 Nirupama Putcha, MD, MHS2 Daniel Belz, MD, MPH2 Molly Lauver, BS2 Wendy Lorizio, MD, MPH2 Kirsten Koehler, PhD3 Ashraf Fawzy, MD, MPH2 Corri K. Hanson, PhD, RD1* Nadia N. Hansel, MD, MPH2*
Author Affiliations
- Medical Nutrition, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, Nebraska, United States
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, United States
- Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, Maryland, United States
* These authors share senior authorship
Address correspondence to:
Mariah K. Jackson, PhD, RDN
984045 Nebraska Medical Center
Omaha, NE 68198-4045
Phone: (402) 836-9892
Email: Mariah.jackson@unmc.edu
Abstract
Background: Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease where diet-derived carotenoids may counteract inflammation and improve COPD outcomes. Our objective was to evaluate associations between serum carotenoid levels and COPD outcomes.
Methods: Low-income individuals with COPD in the Baltimore, Maryland area completed longitudinal assessment including a panel of 10 serum carotenoids, inflammatory and oxidative stress markers, and COPD outcomes. A total carotenoid level was created by summing the individual value for each carotenoid. Adjusted regression analyses were performed to analyze the association between total and individual carotenoids and COPD outcomes.
Results: Of 98 participants, two-thirds had a household income less than $30,000. In adjusted analyses, each standard deviation increase of total and individual carotenoid levels was significantly associated with better COPD-related health scores and associated with lower frequency of severe exacerbations. Total carotenoid levels had an inverse relationship with tumor necrosis factor alpha: -3.0% (-5.1, -0.8), and interleukin-6: -9.5% (-16.0, -2.5).
Conclusion: Higher serum carotenoid levels had a positive impact on COPD health status scores and inflammatory markers, and may lower the incidence of exacerbations. Future research should continue to investigate the role of nutrition as a complementary therapy for lung health.
Citation
Citation: Jackson MK, Woo H, Putcha N, et al. Protective effects of serum carotenoid status on respiratory health among low-income individuals with COPD. Chronic Obstr Pulm Dis. 2026; 13(5): 352-361. doi: http://dx.doi.org/10.15326/jcopdf.2025.0710
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Surya P. Bhatt, MD, MSPH1 Brendan Clark, MS, PharmD2 Mary DuCharme, MLIS3 Phani Veeranki, MD, DrPH3 Timothy L. Barnes, PhD, MPH, MHI, MBA3
Author Affiliations
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
- Optum, Eden Prairie, Minnesota, United States
Address correspondence to:
Timothy L. Barnes, PhD, MPH, MHI, MBA
Optum
Eden Prairie, Minnesota
Email: timothylbarnes@gmail.com
Abstract
Rationale: Inhaled triple therapy (TT) combining a long-acting beta2-agonist, long-acting muscarinic antagonist, and inhaled corticosteroid is recommended for chronic obstructive pulmonary disease (COPD) patients with frequent exacerbations. Despite guideline criteria, TT is often initiated in patients unlikely to benefit.
Objectives: We aimed to characterize trends in the use of TT among COPD patients and concordance with guideline recommendations.
Methods: This observational study used de-identified commercial and Medicare Advantage Part D claims from the Optum Research Database (2018–2022). Patients ≥40 years old with COPD who initiated TT between 2019 and 2022 were included. Baseline characteristics, prior respiratory medication use, and exacerbation history during the 12-month period before TT initiation (index date) were summarized overall and stratified by calendar year and TT type (single-inhaler TT [SITT] versus multiple-inhaler TT [MITT]). A subgroup analysis evaluated maintenance-naive initiators, defined as no maintenance inhaler use in the prior 12 months.
Results: A total of 60,169 patients initiating TT were included. The proportion using SITT increased steadily from 53.0% in 2019 to 79.3% in 2022. Most patients (61.9%) had a low exacerbation history consistent with the Global initiative for chronic Lung Disease (GOLD) group A/B, increasing from 53.0% to 66.0% over the study period. Approximately 40% had zero exacerbations in the previous 12 months. One third of initiators were maintenance naive. SITT use was associated with significantly higher odds of guideline-discordant initiation relative to MITT (adjusted odds ratio 5.04; 95% confidence interval: 4.76–5.33).
Conclusions: TT initiation discordant with GOLD recommendations has increased in the United States, coinciding with an increase in the use of SITT over the corresponding period.
Citation
Citation: Bhatt SP, Clark B, DuCharme M, Veeranki P, Barnes TL. Trends in the use of triple therapy in patients with COPD in the United States, 2019 to 2022. Chronic Obstr Pulm Dis. 2026; 13(5): 362-372. doi: http://dx.doi.org/10.15326/jcopdf.2026.0781
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Yao Zhong, MD1 Meihua Wang, MD1 Qunqun Zhu, MD1
Author Affiliations
- Department of Respiratory Medicine, Hangzhou Xixi Hospital, Hangzhou City, Zhejiang Province, China
Address correspondence to:
Qunqun Zhu, MD
Department of Respiratory Medicine Nurse
Hangzhou Xixi Hospital
No. 2, Hengbu Street
Xihu District, Hangzhou City, Zhejiang Province
310063, China
Phone: +86-13646831297
Email: qunqunzhu8566@163.com
Abstract
Objective: The objectives of this study were to investigate changes in airway microbiota and immune markers across chronic obstructive pulmonary disease (COPD) stages and their associations with clinical phenotypes and nursing factors, providing a basis for precision nursing.
Methods: A total of 284 stable COPD patients (Global initiative for chronic Obstructive Lung Disease [GOLD] grades 2–3) were enrolled. Sputum and clinical data were collected at baseline (T0), exacerbation (T1), and recovery (T2). Microbiota structure was analyzed via 16S ribosomal RNA sequencing, and levels of immune markers such as interleukin-8 (IL-8) and IL-1β were measured by enzyme-linked immunosorbent assay. Statistical analysis was performed by integrating clinical scale scores and nursing adherence data.
Results: At T1, airway microbial α diversity was remarkably lower than at T0 and T2 (p<0.01). The relative abundances of Haemophilus and Prevotella increased, while those of Veillonella and Lactococcus decreased (p<0.01). Levels of IL-8, IL-1β, and tumour necrosis factor alpha were elevated, and secretory leukocyte protease inhibitor levels were reduced at T1 (p<0.01). Notable correlations were found between microbiota and immune markers (e.g., Haemophilus abundance with IL-8 levels, r=0.52, p<0.01), and these were positively associated with clinical scores such as the COPD Assessment Test and St George's Respiratory Questionnaire (p<0.05). Patients with >80% inhaler adherence and regular breathing exercises/nutrition had higher microbial diversity and attenuated inflammation (p<0.05).
Conclusion: The airway microbiota-immune axis in COPD patients demonstrates a disease stage-dependent imbalance, characterized by microbial dysbiosis and enhanced pro-inflammatory responses during acute exacerbation. Good nursing adherence can modulate this axis’s homeostasis, offering novel targets for precision nursing.
Citation
Citation: Zhong Y, Wang M, Zhu Q. Dynamic changes in airway microbiota and immune homeostasis in patients with COPD and the implications for nursing management. Chronic Obstr Pulm Dis. 2026; 13(5): 373-385. doi: http://dx.doi.org/10.15326/jcopdf.2026.0799
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Paul M. Boylan, PharmD1 Devin L. Lavender, PharmD2 Rebecca H. Stone, PharmD2 Russ Palmer, PhD2 Richard L. Lamb, PhD2,3 Kiley Merritt, BS2 Joshua Caballero, PharmD2
Author Affiliations
- College of Pharmacy, University of Oklahoma, Oklahoma City, Oklahoma, United States
- College of Pharmacy, University of Georgia, Athens, Georgia, United States
- College of Veterinary Medicine, University of Georgia, Athens, Georgia, United States
Address correspondence to:
Paul Boylan, PharmD
1110 N Stonewall Ave CPB 239
Oklahoma City, OK, 73117
Phone: (405) 271-6878 x47255
Email: paul-boylan@ou.edu
Abstract
Background: Chronic obstructive pulmonary disease (COPD) management is complex and rapidly evolving. ChatGPT is a large language model (LLM) shown to generate treatment plans for chronic conditions, yet its accuracy, usefulness, and consistency for COPD remain poorly characterized. This study evaluated the accuracy, usefulness, and impact variability of simultaneous ChatGPT-4o responses to COPD medication management questions.
Methods: Five COPD treatment questions were simultaneously entered into 3 separate computers using ChatGPT-4o during a single session, generating 15 total responses. Three residency-trained, board-certified clinical pharmacists rated each response across 3 domains—accuracy, usefulness, and impact variability—using a 3-point ordinal scale (0 to 2) via a 3-round modified Delphi process. Consensus was defined a priori as unanimous agreement among all 3 panelists.
Results: Of 45 response-domain ratings, consensus was achieved in 40 (88.9%). Accuracy ranged from poor (0) to good (2), usefulness from somewhat (1) to very useful (2), and impact variability from low (0) to high (2). For one question on stable COPD pharmacotherapy, all 3 simultaneous responses cited a retired clinical practice guideline, resulting in poor accuracy ratings. For 2 questions—treating exacerbations and managing a complex case—one response per question was rated higher in usefulness than the others.
Conclusions: Simultaneous ChatGPT-4o responses to identical COPD prompts differed materially in accuracy and potential clinical impact. LLM outputs should augment rather than replace clinician judgment and must be deployed with current guideline grounding and appropriate local oversight.
Citation
Citation: Boylan PM, Lavender DL, Stone RH, et al. Accuracy, usefulness, and impact variability of ChatGPT-4o for COPD medication management: a modified Delphi study. Chronic Obstr Pulm Dis. 2026; 13(5): 386-394. doi: http://dx.doi.org/10.15326/jcopdf.2026.0794
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Charlie Strange, MD1,2 Kristen E. Holm, PhD, MPH2,3 Robert A. Sandhaus, MD, PhD2,3 David M. Mannino, MD4 Radmila Choate, PhD, MPH2,5
Author Affiliations
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
- AlphaNet, Inc., Coral Gables, Florida, United States
- Department of Medicine, National Jewish Health, Denver, Colorado, United States
- College of Medicine, University of Kentucky, Lexington, Kentucky, United States
- College of Public Health, University of Kentucky, Lexington, Kentucky, United States
Address correspondence to:
Charlie Strange, MD
Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine
Medical University of South Carolina
Charleston, SC
Phone: (843) 792-3174
Email: strangec@musc.edu
Abstract
Background: Alpha-1 antitrypsin deficiency (AATD) has considerable interindividual variability in lung disease progression. Pulmonary impairment is often measured by forced expiratory volume in 1 second (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO). This study aimed to quantify within-person variability in pulmonary function test (PFT) measures and identify baseline factors associated with variability.
Methods: Adult participants with AATD enrolled in the National Heart, Lung, and Blood Institute Registry (1989–1992) were eligible for inclusion in this analysis if they had 3 serial PFTs and severe genetic deficiency. PFT variability was evaluated using linear mixed-effects models with maximum likelihood estimation. Intraparticipant variability was assessed through residual analyses. Baseline predictors, including age, sex, augmentation therapy, liver disease, and FEV1 percentage predicted, were examined as fixed effects.
Results: The analytic FEV1 cohort (n=832) had a mean age of 46.3 ± 10.1 years, 44.4% were female, and 99% were White. Over a mean of 4.4 ± 1.4 years of follow-up, participants completed an average of 5.7 ± 2.0 spirometry tests. FEV1 varied by more than 10% of baseline in 82% of participants and by more than 20% in 55%. DLCO varied by more than 10% in 91% and by more than 20% in 43% of participants.
Conclusions: Substantial individual variability in FEV1 and DLCO was observed in this large AATD cohort. These findings suggest that FEV1 and DLCO are unreliable as clinical trial or stopping rule endpoints in AATD.
Citation
Citation: Strange C, Holm KE, Sandhaus RA, Mannino DM, Choate R. Lung function variability in alpha-1 antitrypsin deficiency: implications for clinical trials. Chronic Obstr Pulm Dis. 2026; 13(5): 395-405. doi: http://dx.doi.org/10.15326/jcopdf.2026.0790
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Cailey M. Denoncourt, BS1* Mahmoud F. Elfeshawy, MD1* Wenli Ni, PhD1,2 Andrew J. Synn, MD, MPH1 Nicholas J. Nassikas, MD1 Pablo E. Morejón-Jaramillo, MD1 Sophia J. Schortmann, BS1 Wanda Phipatanakul, MD, MS3 Meghan E. Rebuli, PhD4 Mary B. Rice, MD, MPH1,2
Author Affiliations
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
- Department of Environmental Health, Center for Climate, Health, and the Global Environment, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
- Division of Immunology, Boston Children’s Hospital, Boston, Massachusetts, United States
- Department of Pediatrics and Curriculum in Toxicology and Environmental Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
*Co-first authors and contributed equally
Address correspondence to:
Mary B. Rice, MD, MPH
330 Brookline Ave
Dana RW-0659
Boston, MA 02459
Email: mrice1@bidmc.harvard.edu
Abstract
Background: Eosinophilic chronic obstructive pulmonary disease (COPD) is marked by type 2 inflammation, affects more than one-third of people with COPD, and is linked to exacerbation risk and corticosteroid responsiveness. The prevalence and clinical significance of allergic sensitization and elevated immunoglobulin E (IgE) in this subtype are not well understood.
Methods: We analyzed baseline data from 174 former smokers with eosinophilic COPD enrolled in a randomized trial. Participants underwent skin prick testing for 14 regional aeroallergens and total serum IgE measurement. Allergic sensitization was defined as ≥1 positive skin test; elevated total IgE as ≥100IU/mL. We evaluated the prevalence of sensitization and elevated IgE, their overlap with asthma and seasonal allergies, and associations with self-reported allergen exposures. Logistic regression assessed links between atopic conditions, exposures, and sensitization. We also examined associations with COPD-related hospitalizations in the past year.
Results: Among participants (mean age 71.5 years; forced expiratory volume in 1 second percentage predicted 53.0%), 47.1% had allergic sensitization, 32.5% had elevated IgE, and 55.7% had allergic sensitization or elevated IgE. Seasonal allergies and asthma were reported by 59.8% and 43.7%, respectively. Among those without concomitant asthma, 38.8% had allergic sensitization. Cat ownership was associated with cat allergen sensitivity (odds ratio=3.1, 95%: confidence interval 1.1–8.6). Asthma and IgE were associated with sensitization to multiple allergens. Sensitization and IgE were not associated with prior-year COPD hospitalization.
Interpretation: Allergic sensitization and elevated IgE are common in eosinophilic COPD, even without comorbid asthma. These findings support further research into the role of environmental allergens in disease progression and management.
Citation
Citation: Denoncourt CM, Elfeshawy MF, Ni W, et al. Allergic sensitization and serum immunoglobulin E in eosinophilic COPD. Chronic Obstr Pulm Dis. 2026; 13(5): 406-415. doi: http://dx.doi.org/10.15326/jcopdf.2026.0770
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